Request of Medical Records

Request of Medical Records

  • At my request, I authorize:
  • TO MAKE DISCLOSURE TO:
  • OWEN EYE CARE 620 E FIRST ST., NEWBERG, OREGON 97132 PHONE: (503) 847-9183 FAX: (971) 832-8578
  • From:
  • To:
  • Statement of Understanding:
  • Information used or disclosed to this authorization may be subject to redisclosure by the recipient and no longer protected by federal law.
  • I understand and acknowledge that this authorization extends to use and/or disclosure from my medical records which may include treatment for physical and mental illness, alcohol and/or drug abuse, and/or Aids, and/or may include results of an HIV test or the fact that an HIV test was performed.
  • You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment or payment or your eligibility for benefits.
  • This authorization is valid for 180 days unless otherwise revoked by written notice. This does not apply to information already used or disclosed in response to this authorization.
  • You may inspect or copy the protected health information to be disclosed or used under this authorization.
  • MM slash DD slash YYYY